| ICD-9-CM: |
| 625.6 - | Urinary Incontinence in Women |
| 788.3 - | Symptoms Involving Urinary System, Urinary Incontinence |
| 788.30 - | Symptoms Involving Urinary System, Urinary Incontinence, Unspecified; Enuresis NOS |
| 788.31 - | Symptoms Involving Urinary System, Urge Incontinence |
| 788.33 - | Symptoms Involving Urinary System, Mixed Incontinence (Female) (Male); Urge and Stress |
| 788.34 - | Symptoms Involving Urinary System, Incontinence without Sensory Awareness |
| 788.35 - | Symptoms Involving Urinary System, Urinary Incontinence with Post-void Dribbling |
| 788.36 - | Symptoms Involving Urinary System, Urinary Incontinence with Nocturnal Enuresis |
| 788.37 - | Symptoms Involving Urinary System, Urinary Incontinence with Continuous Leakage |
| 788.39 - | Symptoms Involving Urinary System, Urinary Incontinence, Other |
| Urinary incontinence is the involuntary loss of urine. There are several types of urinary incontinence, including stress, urge, overflow, total, and functional. The cause of each type varies. However, there is a great deal of overlap in the conditions, with the result being that one cause may be a factor in more than one type of urinary incontinence.
Stress incontinence results in leakage of urine during coughing, sneezing, jumping, lifting, or even changing position. This is the most common type of urinary incontinence in women. It is often associated with the number of pregnancies and vaginal deliveries, since pregnancy and birth stretch and weaken the muscles at the floor of the pelvis, which can allow the urethra to sag. When the urethra sags down, it takes only a small amount of pressure (from either the abdomen or the bladder) to cause a woman to involuntarily loose urine. Sometimes stress incontinence occurs when the urethra itself malfunctions. Loss of estrogen can also affect the urethra and cause stress incontinence. This is a common cause of stress incontinence in women who are postmenopausal.
Urge incontinence, also sometimes called an unstable bladder, results from an abnormal contraction of the bladder muscle (the detrusor muscle). It is not related to position or activity. The woman can feel the need to urinate but is unable to tighten the valve (sphincter) that controls flow of urine well enough to prevent or stop the flow of urine. A large amount of urine can be lost and under very unpredictable circumstances. It, therefore, has a greater impact on a woman's life than stress incontinence. This condition may coexist with stress incontinence. Conditions that cause urge incontinence include dysfunction of the nerves that control the bladder (which may be due to strokes or Parkinson's disease) and inflammatory conditions of the bladder. Inflammatory conditions may be due to tumors or stones in the bladder but can also occur with acute or chronic inflammatory conditions (cystitis).
Overflow incontinence is seen with a chronically overdistended bladder that never empties, resulting in frequent leakage of urine. This situation may be due to a disorder of the nerves that supply the bladder (as in diabetes) or an obstruction to bladder emptying by urethral narrowing.
Total urinary incontinence is seen when the urethra provides no resistance to the flow of urine. The bladder is unable to store urine, allowing the continuous leak of urine. It can occur with anatomic abnormalities, including an abnormal pathway for urine from the bladder (a fistula), an outpouching of the urethra (diverticulum), or an abnormally located ureter (ectopic ureter). Abnormally located ureters are due to a congenital abnormality. Trauma may also result in abnormalities resulting in total urinary incontinence.
Functional incontinence is not related to abnormalities in the urinary tract. Other factors cause the incontinence. Physical immobility may make it more difficult for the woman to reach or prepare herself for using the toilet. Severe mental impairment or delirium can reduce an individual's understanding that incontinence is not desirable or appropriate. Medication use in the elderly and psychological disturbances may reduce the individual's understanding of what is undesirable or inappropriate urination. Medications that may play a role in functional incontinence include antidepressants, antipsychotics, sedative-hypnotics, and narcotic pain medications. Infection also can result in functional incontinence. Diabetes and lack of estrogen also are causes of functional incontinence. Finally, impacted stools may actually result in urinary incontinence (in addition to fecal incontinence).Risk: Age increases the risk of urinary incontinence: among residents of nursing homes, 38% to 83% have incontinence, whereas only 10% to 15% of women report incontinence early in life (O'Shaughnessy). Menopausal women are more at risk for this condition.
Whites and Japanese are more likely to experience urinary incontinence.
A woman who experiences perineal tears during delivery, has a prolonged and difficult delivery, or has a hysterectomy is more at risk. Smoking and obesity increase the risk of urinary incontinence. Incidence and Prevalence: Among of females older than 60 years who live in the community, 17% to 46% have urinary incontinence; in women aged 15 to 64, the prevalence of urinary incontinence is 10% to 25% (O'Shaughnessy). |
Source: Medical Disability Advisor
| History: With stress incontinence, a woman may report loss of a small amount of urine with sneezing, coughing, laughing, bending, lifting weight, or rising from a sitting to standing position. She may also report the sensation of heaviness in the pelvic area.
With urge incontinence, a woman may report loss of a large amount of urine, frequent voiding, the urge coming too fast to get to the toilet, and the loss of urine at the sound of running water.
In overflow incontinence, there is a report of dribbling urine without being aware of urine loss and the sensation of incomplete emptying of the bladder.
In functional incontinence, the woman may or may not complain of loss of urine, depending on the cause of the functional incontinence. If there is physical disability, there may be a complaint of inability to get to a bathroom on time, the lack of convenient access to a toilet, or the need for assistance in getting on the toilet. If urine loss is due to medication use, the woman may report incontinence. Similarly, women who are postmenopausal or who have diabetes may report incontinence. In cases of delirium or dementia, it may be the caregivers who note incontinence. Women with psychological conditions may report urinary urgency and frequency, but without evidence of abnormality. Women who have a stool impaction may report incontinence of both urine and stool.
The individual may have kept a voiding diary to record factors associated with the incontinence. It may note instances of normal voiding and include information such as timing (day or nighttime), onset, duration, frequency, possible precipitating events, the presence of blood, and an estimation of the amount of urine lost. Medication use should also be included. The history should reflect any neurologic conditions affecting the bladder and urinary sphincter, such as spinal cord injury, stroke, diabetes, Parkinson's disease, or multiple sclerosis. A history of trauma, vaginal surgery, extensive rectal surgery using an incision in the abdomen and perineum, removal of the uterus (radical hysterectomy), radiation therapy, or previous surgical repair of incontinence should be obtained. Other conditions that should be noted include depression, congestive heart failure, and the number of pregnancies. Physical exam: Abnormalities such as a pouch-like protrusion in the wall of the urethra (urethrocele), pouch-like protrusion of the bladder into the vagina (cystocele), a hernia that protrudes through the rectovaginal pouch (enterocele), or a pouch-like protrusion of the rectum into the back wall of the vagina (rectocele) may be revealed. Other abnormal findings may include redness, vaginal or urethral discharge, tissue shrinkage (atrophy), or lax vaginal muscles. A pelvic examination is performed with a full and empty bladder and during coughing or straining, to check for incontinence and sagging of the urethra (prolapse). A thorough neurological exam is helpful. Tests: Tests may include a urinalysis and urine culture. The pad test may be employed to measure involuntary urine loss. Urodynamic testing is often performed, including measurements of bladder capacity, urethral mobility, sensation, pressures within the bladder when full of urine, pressure changes that occur during urination, voluntary control, and pressure in the urethra (cystometry and urethral pressure profile). Visually inspecting the bladder with fiberoptic video cameras (cystoscopy and urethroscopy) may also be performed. It is also helpful to screen for diabetes. MRI may be helpful in visualizing the pelvic floor. EMGs can be helpful for evaluating sphincter strength. An ultrasound of the kidneys may rule out abnormal accumulation of fluid in the kidneys, and helps measure the post-void residual volume (PVR) of urine in the bladder. If there is blood in the urine, an intravenous pyelogram (IVP) and cystourethroscopy can help to determine the etiology. |
Source: Medical Disability Advisor
| Effective treatment requires a correct diagnosis of the cause of incontinence. Any predisposing conditions should be treated first, such as a chronic cough, urinary infection, or estrogen deficiency.
The treatment of stress incontinence may require exercises to strengthen the pelvic floor (Kegel exercises), biofeedback, electrical stimulation of the pelvic floor muscles, drugs, or surgery.
Surgical procedures include repair of cystocele and bladder neck suspension procedures. There are a variety of bladder neck suspension procedures involving either an abdominal or vaginal approach, and the procedure may be performed laparoscopically to repair the urethra. The pubovaginal sling (placement of an artificial sphincter) and periurethral bulking injections may be applied to compress the urethra and increase resistance to urine leakage.
In the case of overflow incontinence, the cause of incomplete bladder emptying must be surgically removed or corrected if possible. Alpha-blockers therapy, avoidance of anticholinergic drugs, intermittent draining of the bladder with a catheter, or even permanent bladder drainage (suprapubic catheterization) may be recommended.
The treatment of urge incontinence may include antibiotic therapy, topical estrogen therapy, or removal of bladder stones or tumors. If urge incontinence is related to neurological diseases, then bladder and bowel training, techniques to assist bladder emptying, urinating according to a schedule, and improvements to aide mobility may be employed. In some cases, management of fluid intake, intermittent catheterization, or the use of external collection devices is appropriate. If urge incontinence is caused by unstable bladder muscles, anticholinergic medications may be beneficial. If anticholinergics fail to help, antiandrogens and luteinizing hormone-releasing hormone (LHRH) analog can be used. A procedure in which parts of the nerves are removed and a sacral electrode is placed helps detrusor contraction and bladder emptying.
The treatment of functional incontinence may include a number of different approaches. Functional incontinence that is related to sleeping pills, diuretics, or alcohol requires restriction or avoidance of the offending substance. Anticholinergic drugs must be avoided. If incontinence is related to sensory deficits, an inability to remove clothing quickly or easily, or restricted access to the toilet, aids such as eyeglasses, hearing aids, easy-to-remove clothing, and convenient toilet facilities should be provided. If incontinence is related to dementia, assisting the individual to the toilet at regularly scheduled times may be attempted.
Incontinence due to stool impaction is treated by relieving the impaction. If incontinence is related to lack of estrogen, medication with estrogen may be recommended. Urinary tract infections causing incontinence are treated with antibiotics. Tricyclic antidepressants are effective for mixed etiologies of urinary incontinence. |
Source: Medical Disability Advisor
| The outcome depends on successful treatment of the underlying condition or cause of the incontinence. The great majority of individuals with stress incontinence can be significantly helped. Kegel exercises and electrical stimulation to the pelvic floor may relieve symptoms of stress incontinence in many women. About half of women treated for stress incontinence with surgical correction void normally with no further symptoms in 5-year follow-ups. Urge incontinence and overflow incontinence are more likely to recur or become a chronic condition. Treatment of urinary tract infection should relieve all symptoms. Removal of stones from the bladder should also relieve all symptoms of incontinence. Bladder training programs provide great relief. In individuals with urge incontinence, bladder training helps 75%, and anticholinergics help 83% (Guerrero).
Incontinence due to dementia and mental health disorders may continue unless there is resolution of the underlying condition.
Estrogen replacement may provide relief of symptoms for women with stress incontinence. |
Source: Medical Disability Advisor
| Rehabilitation procedures such as Kegel exercises, electrical stimulation to the pelvic area, and bladder training programs may be used for treatment of incontinence. Kegel exercises involve tightening the muscles in the pelvis that are used for urination for 10 to 20 seconds, and then relaxing them. This is repeated several times, at least 4 times a day, in order to build up the strength of muscles in the urethral area. Pelvic electrical stimulation helps functioning of the bladder muscle (detrusor muscle), relieving incontinence in about 35% to 60% of people with urinary incontinence (Guerrero). Bladder training programs involve a schedule of voiding every 2 hours. The length of time between voiding is gradually increased as the woman learns to maintain control. |
Source: Medical Disability Advisor
| Complications may occur as a result of backward flow of urine toward the kidneys (ureteral reflux), enlargement of the urinary drainage system (hydronephrosis), bladder or kidney infection, or chronic kidney failure. Perineal skin damage and infection can result without appropriate preventive skin care. Surgery has a 20% chance of causing complications in patients who have stress incontinence (Guerrero).
The inability to control urine can interfere with a woman's enjoyment of her social relationships, work, and sex life. It can lead to social isolation and disability. |
Source: Medical Disability Advisor
| Lifting should be avoided, as should environments that trigger sneezing or coughing and changing positions too often. Certain noises (for example, running water) may provoke urination, so workplaces with these noises should be avoided. Individuals at work should have easy and regular access to bathroom facilities. Work restrictions and accommodations may be needed following bladder neck suspension procedures.
Work restrictions and accommodations may also be needed for surgical correction of other problems that contribute to the incontinence. Restrictions and accommodations may include no heavy lifting, a shorter workday, and time off for follow-up appointments. In some situations, catheters may be placed in the bladder for several days to a couple of weeks following the procedure. Employees returning to work with catheters in place may need accommodations so that the catheter bag may be emptied and the catheter may be maintained. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does individual have a history of multiple childbirths?
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Has individual gone through menopause?
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Has individual been referred to an appropriate specialist (urologist, gynecologist)?
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Has woman kept a "voiding diary" to help identify the circumstances that precipitate incontinence?
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Were any physical abnormalities in the genitourinary system noted on physical exam?
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Was a urodynamic test performed?
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Has the type of incontinence been identified?
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Has the cause of the incontinence been established?
Regarding treatment:
- Has weight loss or medication been effective in relieving symptoms?
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Has a long enough trial of medication been done to gauge effectiveness?
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Has individual been encouraged to perform Kegel exercises to strengthen pelvic floor muscles? Have other strengthening tools been tried?
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Have other nonsurgical treatments, such as electrical stimulation or collagen injections, been tried?
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Have exercises or other nonsurgical methods been effective in reducing incontinence?
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If nonsurgical methods have failed to reduce symptoms, is surgical intervention now warranted?
Regarding prognosis:
- Based on the type of treatment required, has adequate time elapsed for complete recovery?
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Have all associated conditions that contribute to the incontinence (mental health disorders, urinary tract infection, estrogen deficiency) been addressed in the treatment plan?
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Would individual benefit from consultation with an appropriate specialist (psychiatrist, neurologist, gynecologist)?
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Is individual an appropriate candidate for surgical intervention?
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Has individual experienced any associated complications (reflux, bladder or kidney infection, kidney dysfunction, or perineal excoriation) that could affect recovery and prognosis? If so, are these complications being addressed in the treatment plan?
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Source: Medical Disability Advisor
| Guerrero, Pilar, and Richard Sinert. "Urinary Incontinence." eMedicine. Eds. Peter M. C. DeBlieux, et al. 18 Nov. 2004. Medscape. 5 Jan. 2005 <http://emedicine.com/emerg/topic791.htm>.O'Shaughnessy, Michael. "Incontinence, Urinary: Comprehensive Review of Medical and Surgical Aspects." eMedicine. Eds. Martha Terris, et al. 9 Dec. 2004. Medscape. 5 Jan. 2005 <http://emedicine.com/med/topic2781.htm>. |
Source: Medical Disability Advisor
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